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Commonwealth of Massachusetts
City/Town of
System (Pumping Record
Form 4
RECEIVED
JUL 07 2014
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by focal Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
City/Town State Zip Code
2. System Owner:
Mc, %n n
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
Ba Pumping Record
1. Date of Pumping 2. Quantity Pumped: f�
Date Gallons
3. Type of system: [] Cesspool(s) 1� Septic Tank ❑ Tight Tank Q Grease Trap
El Other (describe);
4. Effluent Tee Filter present? 0 Yes ❑ No If yes, was it cleaned? (3 Yes 0 No
5. Condition of System:
B. System Pumped By:��'�_
Name Vehicle License Number
Stewart's $etic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of klauler
Date
Signature of Receiving Facility Date
t5form4.doc• 03/06 System Pumping Record . Page 1 of 1
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Town of North Andover
Building Department
1600 Osgood Street Bldg 20, Suite 2035
North Andover MA 01845
Tel: 978-688-9545 Fax: 978-688-9542
DEMOLITION OF BUILDING AFFIDAVIT
LOCATION OF PROPERTY TO DEMOLISH
DESC
CONTRACTOR'S NAME & ADDRESS
DEPARTMENT SIGN -OFFS
DEPT. OF PUBLIC WORKS -WATER: SEWER:
TREE WARDEN
HISTORIC COMMISSION
PLANNING
GAS
ELECTRIC
TELEPHONE
TAXES
POLICE
FIRE
EXTERMINATOR
DUMPSTER - ON/OFF STREET DIG SAFE NUMBER
BLDG. INSPECTOR
Building Demolition Affidavit
�
Commonwealth of Massachusetts
City/Town of North Andover
�`�<j �5 �ii
I2TowN
-o
System Pumping Record
HLALGTH pEpR�Npp�ER
M
Form 4
AMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms
on the computer,
1. System Location:-7 a C� (\-�W
r�
use only the tab
'
key to move your
Address
cursor - do not
North Andover Ma
use the return
key.
City/Town State
Zip Code
2. System Owner:
kV v i n nY.
rznm
Name
Address (if different from location)
City/Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dace f 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System: Qlc_�,-d
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
re Hauler Date
S5 -",U re of Receiving Facility Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
TOWN F NORTH" ANDOVER
4
7PUMPINQ RECORD
UA tl,
SYSTEM OWNER .& ADDRESS SYSTE
r-tr%nvvIbYSTE LOCATION
v
c op
DATE OF PUMPING: c
PUMPED:...
'L'SSW-XJL: NO YES
OPdC 1'allk: NU- YES
NASURE OF' SERVICE:
RECEIVED
OCT 6 5 2004
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
0138F.RVAnONS:
GOOD CONDI'FION FULL'Iyj COVER
HEAVY OREASE BAFFLES IN PLACE
ROOTS LEACKFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER, '*....-,...-OTtfF,R EXPLAIN
systompumpodby
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: / d
SYSTEM OWNER & ADDRESS
/v1
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: 0;)6`6 i QUANTITY PUMPED !Q52t-) GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: J40 C fi? l / ` S)�,-